ATI Engage Fundamentals: Tissue Integrity- Posttest Complete Questions And Answer

ATI Engage Fundamentals : Tissue Integrity - Posttest Complete Questions And Answer A nurse is providing teaching to a client who is in a wheelchair about measures to avoid skin breakdown. Which of the following instructions by the nurse is related to preventing skin breakdown? ✔✔You should shift your weight off your buttocks at intervals throughout the day A wound, ostomy and continence nurse (WOCN) is providing an in service to a group of nurses about documentation of pressure injuries. Which of the following statements by one of the group members indicates an under standing of the teaching? ✔✔Pressure injury documentation includes location, stage, measurements and condition of the wound bed and any drainage present A nurse is caring for a client who has sustained a gunshot wound to the abdomen and is 6 hr postoperat ive. The nurse notices protrusion of the client's organs from the incision site and call for help. Which of the following actions should the nurse take? ✔✔Cover the client's wound with a sterile saline dressing A nurse is teaching assistive personnel (AP) about the skin of older adults. Which of the following statements by the AP indicates an understanding of the teaching? ✔✔The skin of older adults is thinner and has less subcutaneous padding over bony prominences A nurse is preparing to obtain a wound culture from a client who has a suspected wound infection. Which of the following actions should the nurse take? ✔✔Clean the wound with 0.9% sodium chloride A nurse is assisting with the care of a client following ab dominal surgery. The nurse removes the client's surgical dressing and notes a separation of the wound edges. The nurse should identify that the client is experiencing which of the following complications? ✔✔Dehiscence A nurse is providing teaching to a cl ient about staple removal. Which of the following statements should the nurse include in the teaching? ✔✔Your staples will be removed in about 2 weeks A nurse is caring for a group of clients. Which of the following clients should the nurse identify as ha ving the highest risk for developing alterations in tissue integrity? ✔✔A client who is incontinent and taking a prescribed diuretic A nurse is caring for a client who has dime -sized stage 1 pressures injury located on the sacrum. Which of the following d ressing types should the nurse use? ✔✔A transparent film